Is Japan's Cancer Care System Sustainable?
While out-of-pocket costs for patients are relatively low, Japan's public health insurance system is beginning to buckle as doctors continue to use increasingly expensive therapies to fight cancer.
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What’s new: The Japan Clinical Oncology Group (JCOG), a group of cancer specialists from across Japan, has launched a survey of the actual costs of treating 17 types of cancer, including the leading killers, stomach and breast cancer, to provide a data-driven approach for considering whether current practice is sustainable.
Zoom in: Pharmacologic breakthrough technology is often an enticing, effective tool for many oncologists. To date, JCOG has found that while 14% of patients are treated exclusively with conventional drugs, 56% of patients are treated with new, more expensive drugs. Although many of these new drugs have been shown to prolong patient survival when used in combination with conventional drug therapy, the study group found that the percentage of patients treated with the new drugs in Europe and the United States was lower than in Japan, at the rate of only 30-40%.
Why it matters: The development of groundbreaking new drugs has made it possible to treat cancer more effectively, but the cost of medical treatment, which is covered by insurance premiums, taxes, and patient co-pays, continues to increase year after year, raising concerns about the impact on health insurance finances.
While society may dictate the use of increasingly expensive treatments for cancer, an even more proactive approach to preventing cancer in the first place must be part of any discussion related to the cost of care.
Japan's healthcare system already does a good job of promoting preventive medicine, but many cancers are caused by lifestyle and environmental factors that can be addressed before a cancer develops. Preventing and managing cancer by taking appropriate action against avoidable risk factors is expected to not only save lives, but also reduce the economic burden.
By the numbers: Cancer is widespread in Japan, and how to pay for treatment is a growing problem.
Leading Cause of Death: Cancer has been the leading cause of death in Japan since 1981, and the number of cancer patients is increasing. In 2020, there were a total of 1.2 million cancer inpatients and 7.1 million cancer outpatients. The top three types of cancer in men are prostate cancer (about 50%), stomach cancer (29%), and colorectal cancer (21%). While breast cancer accounts for the vast majority of cancers in women (65%), colorectal cancer (19%) and stomach cancer (15%) are also common.
High Likelihood of Developing Cancer: According to the National Cancer Center, 65.5% of men and 51.2% of women will develop cancer at least once in their lifetime.
Tendency to Prescribe Relatively Expensive, State-of-the-Art Medicine: JCOG has found that, among 700 patients diagnosed with stage 4 cancer at 38 hospitals nationwide during the latest fiscal year, treatment with conventional drugs cost only 16,383 yen (U.S. $102). Treatment with new drugs introduced after 2015 in addition to conventional drugs ranged from 270,874 yen ($1,691) to 424,746 yen ($2,652), a 17- to 26-fold increase.
Overall Economic Burden: The total economic burden of cancer is approximately 2,859.7 billion yen ($18 billion) per year.
Almost 1/3 of the Economic Cost Is Preventable: The economic burden of cancers attributable to preventable risk factors was approximately 1,024.4 billion yen ($6.4 billion), with stomach cancer having the highest economic burden for both men and women, followed by lung cancer mainly for men and cervical cancer for women.
Go deeper: There are three typical treatments for cancer: surgery, drug therapy, and radiation therapy. Each of these treatments is sometimes used independently, but sometimes they are used together (multidisciplinary treatment).
Surgery in cancer treatment aims to remove the cancer or cancerous organ. If the normal function of the organ is lost as a result of the resection, surgery is also performed to restore the function (reconstructive surgery). If the cancer is confined to the original site (primary site), there is a good chance that the patient will be cured by surgically removing all of the cancer.
Radiation therapy is a treatment in which artificially produced radiation is delivered to the affected area to kill cancer cells. Radiation therapy is also used to relieve symptoms such as pain caused by bone metastases. Compared to surgery, radiation therapy does not require anesthesia and is used in many cancer treatments because it is less stressful to the body.
Cancer drug therapy is a treatment used to cure cancer, control the progression of cancer, and relieve symptoms caused by cancer. It is sometimes called "chemotherapy.” Cancer drug therapy can be given in the hospital or as an outpatient. With the development of technology to reduce side effects, outpatient treatment is becoming more common.
Some of the above treatments fall under the category called "advanced medical treatment" in Japan.
How it works: For treatment covered by national health insurance, residents of Japan generally pay 30% of the total medical cost. However, to limit out-of-pocket expenses, Japan uses its "high-cost medical care cost system" to ensure that patients do not have to pay more than a certain threshold amount. The limits depend on the patient's age and income level1.
However, "advanced medical treatment2" is not covered by public medical insurance. Patients are required to pay the full cost of advanced medical treatment and are not exempt from paying more than a certain amount under the high-cost medical care cost system.
Details: The following is an example of the out-of-pocket costs for standard cancer treatment at the Tokyo Metropolitan Cancer Screening Center followed by surgery and outpatient care at St. Luke's International Hospital in Tokyo.
Single-day Screening: Standard barium stomach examination: 29,920 yen ($186)
Surgery: Lung cancer (thoracoscopic lobectomy): 600,000 yen ($3,750) = 30% co-payment
Drug Treatment: For example, Paclitaxel once-weekly therapy (18 times for a patient with a body surface area of 1.5 square meters): 160,000 yen ($1,000) = 30% co-pay
There are also costs for just staying in the hospital. If you request a private room during your hospital stay (highly recommended), you will be charged a premium. The average cost of a "single room" is 8,221 yen ($51) per day. The premium for a private room is not covered by national health insurance.
All premium room rates must be multiplied by the number of days in the hospital, which varies depending on the type of cancer. Here are some examples of average inpatient stays, which tend to be long in Japan:
Gastric Cancer: 22.3 days
Colorectal Cancer: 16.4 days
Liver and Intrahepatic Bile Duct Cancer: 20.8 days
Trachea, Bronchus, and Lung Cancer: 21.1 days
In addition, under the "inpatient food care cost" system, a portion of the cost of food during hospitalization is also to be borne by the patient, but it tends to be very low. The amount of the co-pay varies according to household income, but a typical household must pay only 460 ($2.87) yen per meal.
If supplemental treatment above and beyond the above type of care regiment were recommended, then the patient may need to consider the following type of “advanced medical treatment.” An example is heavy ion beam therapy which could cost around 2,176,000 yen ($13,600) per treatment.
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The bottom line: While most patients do not require advanced medical treatment, if they do, there tends to be a significant difference in both the total cost of care and the patient's out-of-pocket expenses.
Here are some specific examples of the out-of-pocket expenses for two typical patients at Minoh City Hospital in Osaka.
Patient 1 – Routine Case Only for Surgery: This patient was hospitalized for 14 days for colon cancer surgery. While the actual cost of care was 1.5 million yen ($9,400), his co-pay was only 100,250 yen ($626) thanks to the application of Japan’s "high-cost medical care cost system.”
Surgery (after application of the high-cost medical care cost system threshold): 92,430 yen ($577)
Advanced Medical Care: 0 yen ($0)
Food (17 meals): 7,820 yen ($49)
Private Room Premium3: 0 yen ($0)
Total Out-of-Pocket Expenses: 100,250 yen ($626)
Patient 2 – Typical Out-Patient: This patient received outpatient anticancer treatment for stomach cancer. She also required home health care and home nursing services.
Outpatient Treatment: 57,600 yen (maximum co-pay, $360)
Prescription at Pharmacy: 5,000 yen ($31)
Home Visits (once per week): 34,000 yen ($212)
Home Nursing Care (twice a week): 23,000 yen ($144)
Total Out-of-Pocket Expenses (before refund4): 119,600 yen ($747)
Total Out-of-Pocket Expenses (after refund): 57,600 yen ($360)
Thus, out-of-pocket costs for most cancer patients tend to be quite reasonable. However, the total cost of care is much higher. This raises the question of whether the current system of cost sharing is sustainable.
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What they’re saying: Not surprisingly, many healthcare professionals in Japan strive to provide their patients with the latest technology. However, most are aware that it is simply not reasonable to assume that "anything goes.”
"It is important for patients to enjoy the benefits of good medicine to fight cancer, but thus far in Japan, doctors and patients have, in general, not been aware of the price of medicine. Since financial resources for medical care are limited, we would like to use the survey to understand the actual situation and leverage the data for a deeper discussion about how to pay for the actual, overall cost of care on an ongoing basis.” - Dr. Takahiro Osawa of Hokkaido University Hospital, a JCOG member who conducted the prostate cancer survey
Some physicians are now taking a practical approach to tackling the cost of care.
"Medical advances have led to effective but extremely expensive drugs, and their impact on finances can no longer be ignored...Medical care has, essentially, thus far been considered a sacred field, but there is a limit to the resources available for medical care, and we have entered an era in which we must think about how to use them." - Dr. Igarashi Naka, Special Associate Professor at the University of Tokyo Graduate School of Pharmaceutical Sciences and an expert in health economics
Commentary: While no health care system is a panacea, Japan's overall method of providing generally high-quality medical care at a reasonable cost to the patient seems to be working well.
Everyone in Japan has health insurance, regardless of employment status or income. This ensures that all residents of Japan access to basic medical care. The country boasts some of the best health outcomes in the world, with high life expectancy and low infant mortality. The system emphasizes preventive care, with regular check-ups and vaccinations encouraged. Doctors have a strong influence on hospital management, which prioritizes patient care over profit. Private insurance is supplemental, covering costs not met by public insurance and offering additional benefits.
Some may balk at the relatively high percentage of out-of-pocket expenses (30%), but the threshold for limiting such charges kicks in at a relatively low level. While the cost of advanced medical procedures is not covered by public insurance and can be expensive, such care is only needed in relatively unusual circumstances.
My one and only experience (knock on wood) as an inpatient in a Japanese hospital provided direct exposure to how a patient is evaluated and treated for a relatively routine but serious illness. See "Brush with Disaster at the End of Japan's Golden Week: First-hand account of my week-long stay being poked, prodded, and pricked in a Japanese hospital to recover from a life-threatening illness" for more details. Once treated, I was able to recover quickly with no complications.
Had I been admitted for cancer treatment, I might have had a different perspective on the experience.
Compared to medical care in my own country, the U.S., where there is extreme inequality in health care, the Japanese system seems to meet the needs of almost all of its residents with a good balance of high-quality care at a reasonable cost (to the patient). The key will be whether the public health insurance system can continue to cover the ever-increasing costs of state-of-the-art care for a rapidly aging country facing a major demographic shift. It is a question of sustainability, as some of the physicians in the JCOG study pointed out.
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What do you think? As a resident of Japan, are you generally satisfied with the country's health care system? All responses are completely anonymous, even to the author.
Links to Japanese Sources: https://www3.nhk.or.jp/news/html/20240608/k10014474911000.html, https://www.ncc.go.jp/jp/information/pr_release/2023/0802/index.html, and https://hoken-navi.docomo.ne.jp/life-ins/column/medical/how-much-doesit-cost.html.
#JCOG #JapanClinicalOncologyGroup #oncology #HealthcareEconomics #HealthcareCost #CancerTreatment #AdvancedMedicalTreatment #医療経済 #医療費 #がん治療 #治療費 #日本臨床腫瘍研究グループ #差額ベッド代 #公的医療保険 #入院時食事療養費 #傷病手当金 #高額療養費制度 #通院治療費 #先進医療
The system also has a household component. If multiple people in a single household exceed the individual threshold in a month, the combined amount might qualify for high-cost medical care benefits. There are, moreover, exceptions for specific diseases like hemophilia or chronic nephritis requiring dialysis. These patients might have lower monthly co-pays.
If Patient 2 (see below) had required "advanced medical treatment," all costs associated with that portion of the treatment would have to be paid in full by the patient. Actual costs vary depending on the type of advanced medical treatment, the medical institution, and the patient's condition. Advanced medical treatment as defined by the Ministry of Health, Labor and Welfare is broadly divided into two types: "Advanced Medical Treatment A" and "Advanced Medical Treatment B." Type A generally costs from several hundred thousand yen (a few thousand dollars) to about one million yen ($6,244). Type B costs from 1 million yen to several million yen (tens of thousands of dollars).
Few patients receive such treatment, mainly due to the fact that only a limited number of medical facilities provide such care. For example, a heavy particle therapy facility requires an area the size of a football field, and there are only seven medical centers in Japan that provide such care. In 2022, the number of patients who received Type A "advanced medical care" was 25,011, and the number of Type B patients was only 1,545.
Some of the most common examples of "advanced medical care" are the following procedures:
Proton Therapy (陽子線治療): 2,659,010 yen ($16,600)
Heavy Particle Therapy (重粒子線治療): 3,135,656 yen ($19,600)
Uterine Adenomyosis Enucleation Using a High-Wave Ablation Device (高波切周除器を用いた子宮腺筋症核出術): 300,000 yen ($1,873)
Drug Resistance Gene Testing for Anti-Cancer Drug Therapy (抗悪性腫瘍剤治療における薬剤耐性遺伝子検査): 37,514 yen ($234)
However, proton beam therapy and heavy particle therapy are covered by public health insurance for some indications.
Patient 1 chose not to have a private room. Had he opted for this added expense, he would have paid an additional 8,221 yen ($51) per day for 14 days = 115,094 yen ($719).
Must be paid prior to "discharge" or, in this case, final outpatient treatment at the hospital. The reimbursement is usually returned to the patient a few months later after an audit of the actual expenses.
I’ve had many friends and family members enjoy much success treating cancer using non-allopathic methods. Rick Simpson oil being one of the most effective I’ve seen. But you have to use the right strain, and prepare it properly. Much what is being sold is not real Rick Simpson oil. Well written, informative article Mark! Thank you!
Another super informative article, Mark! Thank you!